Quetiapine improves sleep disturbances in combat veterans with PTSD: sleep data from a prospective, open-label study

Pharmacological Management of Nightmares Associated with Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) can be a chronic and disabling condition. Post-traumatic nightmares (PTNs) form a core component of PTSD and are highly prevalent in this patient population. Nightmares in PTSD have been associated with significant distress, functional impairment, poor health outcomes, and decreased quality of life. Nightmares in PTSD are also an independent risk factor for suicide. Nightmare cessation can lead to improved quality of life, fewer hospital admissions, lower healthcare costs, and reduced all-cause mortality. Effective treatment of nightmares is critical and often leads to improvement of other PTSD symptomatology. However, approved pharmacological agents for the treatment of PTSD have modest effects on sleep and nightmares, and may cause adverse effects. No pharmacological agent has been approved specifically for the treatment of PTNs, but multiple agents have been studied. This current narrative review aimed to critically appraise proven as well as novel pharmacological agents used in the treatment of PTNs. Evidence of varying quality exists for the use of prazosin, doxazosin, clonidine, tricyclic antidepressants, trazodone, mirtazapine, atypical antipsychotics (especially risperidone, olanzapine and quetiapine), gabapentin, topiramate, and cyproheptadine. Evidence does not support the use of venlafaxine, β-blockers, benzodiazepines, or sedative hypnotics. Novel agents such as ramelteon, cannabinoids, ketamine, psychedelic agents, and trihexyphenidyl have shown promising results. Large randomized controlled trials (RCTs) are needed to evaluate the use of these novel agents. Future research directions are identified to optimize the treatment of nightmares in patients with PTSD.

Pharmacotherapy of 1,044 inpatients with posttraumatic stress disorder: current status and trends in German-speaking countries

Posttraumatic stress disorder (PTSD) is a debilitating psychiatric disorder with limited approved pharmacological treatment options and high symptom burden. Therefore, real-life prescription patterns may differ from guideline recommendations, especially in psychiatric inpatient settings. The European Drug Safety Program in Psychiatry ("Arzneimittelsicherheit in der Psychiatrie", AMSP) collects inpatients' prescription rates cross-sectionally twice a year in German-speaking psychiatric hospitals. For this study, the AMSP database was screened for psychiatric inpatients with a primary diagnosis of PTSD between 2001 and 2017. N = 1,044 patients with a primary diagnosis of PTSD were identified with 89.9% taking psychotropics. The average prescription rate was 2.4 (standard deviation: 1.5) psychotropics per patient with high rates of antidepressant drugs (72.0%), antipsychotics drugs (58.4%) and tranquilizing drugs (29.3%). The presence of psychiatric comorbidities was associated with higher rates of psychotropic drug use. The most often prescribed substances were quetiapine (24.1% of all patients), lorazepam (18.1%) and mirtazapine (15.0%). The use of drugs approved for PTSD was low (sertraline 11.1%; paroxetine 3.7%). Prescription rates of second-generation antipsychotic drugs increased, while the use of tranquilizing drugs declined over the years. High prescription rates and extensive use of sedative medication suggest a symptom-driven prescription (e.g., hyperarousal, insomnia) that can only be explained to a minor extent by existing comorbidities. The observed discrepancy with existing guidelines underlines the need for effective pharmacological and psychological treatment options in psychiatric inpatient settings.

Quetiapine augmentation of prolonged exposure therapy in veterans with PTSD and a history of mild traumatic brain injury: design and methodology of a pilot study

BACKGROUND

Selective serotonergic reuptake inhibitors (SSRIs) are first-line pharmacologic treatments for patients with posttraumatic stress disorder (PTSD), but must be given over extended period of time before the onset of action. The use of SSRIs in PTSD patients with mild traumatic brain injury (mTBI) is problematic since SSRIs could exacerbate post-concussion syndrome (PCS) symptoms. VA/DOD guidelines identify trauma-focused psychotherapy as the best evidence-based treatment for PTSD, but overall effectiveness is limited by reduced levels of patient engagement and retention. A previous study from this research group suggested that quetiapine monotherapy, but not risperidone or valproate, could increase engagement in trauma-focused psychotherapy.

METHODS

We report the study protocol of a pilot study funded under the South-Central Mental Illness Research, Education, and Clinical Center pilot study program from the U.S. Department of Veterans Affairs. This randomized, open-label study was designed to evaluate the feasibility of completing a randomized trial of quetiapine vs. treatment as usual to promote patient engagement in PTSD patients with a history of mTBI.

DISCUSSION

We expect that the success of this ongoing study should provide us with the preliminary data necessary to design a full-scale randomized trial. Positive efficacy results in a full- scale trial should inform new VA guidelines for clinical practice by showing that quetiapine-related improvements in patient engagement and retention may be the most effective approach to assure that VA resources achieve the best possible outcome for veterans.

TRIAL REGISTRATION

NCT04280965 .

Trauma, posttraumatic stress disorder severity, and positive memories

Positive memories play an important role in the aetiology and maintenance of posttraumatic stress disorder (PTSD). However, most trauma research/clinical work has focused solely on the role of traumatic memories. Thus, we examined the relationship between count of retrieved positive memories and PTSD severity, factors associated with count of retrieved positive memories (i.e., rumination, negative/positive emotion dysregulation, fear of positive emotions), and the relationship between positive memory phenomenological domains and PTSD severity. The sample included 185 trauma-exposed participants recruited through Amazon's Mechanical Turk (Mage = 35.69 years; 63.80% female). Results of linear/hierarchical regressions showed that (1) PTSD severity did not predict count of (specific) positive memories; (2) greater positive emotion dysregulation predicted fewer retrieved positive memories controlling for PTSD severity; and (3) greater PTSD severity predicted more negative valence, less vividness, less coherence, less accessibility, less clear time perspective, fewer sensory details, and greater distancing ratings of the retrieved positive memory, controlling for sleep quantity/quality. Findings add to the literature by informing PTSD theoretical perspectives; enhancing an understanding of positive memories in PTSD/trauma treatments; and highlighting potential clinical targets (e.g., positive emotion regulation), when integrating a focus on positive memories into PTSD intervention.

Enhancing Completion of Cognitive Processing Therapy for Posttraumatic Stress Disorder with Quetiapine in Veterans with Mild Traumatic Brain Injury: a Case Series

To evaluate the outcomes of the antiarousal medications valproate, risperidone, and quetiapine on completion of treatment of cognitive processing therapy (CPT) for PTSD. A case series of fifty treatment-seeking adult (≥18 years) veterans with mild traumatic brain injury and combat-related PTSD who had unsuccessful trials of 2 or more first-line agents and previously declined treatment with trauma-focused therapy, seen at the psychiatric outpatient services of the local Polytrauma Rehabilitation Center from January 1, 2014, through December 31, 2017. Patients were prescribed valproate (n = 8), risperidone (n = 17), or quetiapine (n = 25) and were referred for individual weekly treatment with CPT. Outcome measurements of interest were measures of engagement and completion rate of CPT, PTSD Checklist total score (range, 0-80; higher scores indicate greater PTSD severity) and arousal subscale score (range, 0-24; higher scores indicate greater arousal severity), and clinical observations of sleep variables. Of the 50 patients included in the study, 48 (96%) were men; mean (SD) age was 36 (8) years. Eighteen (86%) patients initially receiving quetiapine and none taking valproate or risperidone became adequately engaged in and completed CPT. Among patients who completed CPT, the mean decrease in the PTSD Checklist score was 25 [95% CI, 30 to 20] and 9 (50%) patients no longer met criteria for PTSD. These preliminary findings support quetiapine as an adjunctive medication to facilitate CPT. A pragmatic trial is needed to evaluate the efficacy, safety, and feasibility of quetiapine to improve engagement in and completion rate of CPT.

Drug treatment strategies for insomnia in patients with post-traumatic stress disorder

INTRODUCTION

Insomnia is among the most reported sleep disturbances in patients with post-traumatic stress disorder (PTSD). The pervasiveness of this disorder among trauma-inflicted civilians and military personnel has been associated with reduced quality of life, impaired psychosocial functioning including cognitive impairments, negative mood swings, cardiovascular complications, and increased utilization of medical services.

AREAS COVERED

This review describes the current state of science with respect to the impact of the most dispensed pharmacological interventions for posttraumatic insomnia. At the present, there are no established treatment algorithms for PTSD-related insomnia. Pharmacotherapy offers an alternative treatment modality for patients with PTSD who fail or decline cognitive behavioral therapy (CBT). Selection of a hypnotic/sedative agent should be based on the patient's history, precipitating and perpetuating factors of insomnia, side effect profile, and potential medication-related interactions. Antipsychotics and benzodiazepines appear ineffective or are associated with significant harm in treating PTSD-related insomnia.

EXPERT OPINION

In the absence of randomized controlled trials, prescription patterns have been guided by anecdotal reports and expert opinion. Due to the complexity and multifactorial etiology of insomnia in PTSD, clinical investigations should examine available pharmacologic agents in comparative trials or in combination with CBT or complementary therapies to assess both short-term and long-term sleep outcomes in this population.

Drugs for Insomnia beyond Benzodiazepines: Pharmacology, Clinical Applications, and Discovery

Although the GABAergic benzodiazepines (BZDs) and Z-drugs (zolpidem, zopiclone, and zaleplon) are FDA-approved for insomnia disorders with a strong evidence base, they have many side effects, including cognitive impairment, tolerance, rebound insomnia upon discontinuation, car accidents/falls, abuse, and dependence liability. Consequently, the clinical use of off-label drugs and novel drugs that do not target the GABAergic system is increasing. The purpose of this review is to analyze the neurobiological and clinical evidence of pharmacological treatments of insomnia, excluding the BZDs and Z-drugs. We analyzed the melatonergic agonist drugs, agomelatine, prolonged-release melatonin, ramelteon, and tasimelteon; the dual orexin receptor antagonist suvorexant; the modulators of the α₂δ subunit of voltage-sensitive calcium channels, gabapentin and pregabalin; the H₁ antagonist, low-dose doxepin; and the histamine and serotonin receptor antagonists, amitriptyline, mirtazapine, trazodone, olanzapine, and quetiapine. The pharmacology and mechanism of action of these treatments and the evidence-base for the use of these drugs in clinical practice is outlined along with novel pipelines. There is evidence to recommend suvorexant and low-dose doxepin for sleep maintenance insomnia; there is also sufficient evidence to recommend ramelteon for sleep onset insomnia. Although there is limited evidence for the use of the quetiapine, trazodone, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine as treatments for insomnia disorder, these drugs may improve sleep while successfully treating comorbid disorders, with a different side effect profile than the BZDs and Z-drugs. The unique mechanism of action of each drug allows for a more personalized and targeted medical management of insomnia.

Management of nightmares in patients with posttraumatic stress disorder: current perspectives

Nightmares are considered the hallmark of posttraumatic stress disorder (PTSD). Although the characteristics of these distressing dreams may vary with the type of traumatic event, the pathophysiology exposes central dysfunction of brain structures at the level of the hippocampus, amygdala, and locus coeruleus, modulated by neurochemical imbalance in nor-adrenergic, dopaminergic, and serotonin pathways. Underlying comorbid conditions, including other sleep disorders, may contribute to worsening symptoms. Addressing sleep disruption can alleviate the severity of these nocturnal events and augment the effectiveness of other PTSD treatments. The expansion of behavioral treatment modalities for PTSD-related nightmares has been encouraging, but the core of these interventions is heavily structured around memory manipulation and imagery rescripting. A lack of a standardized delivery and a high dropout rate continue to pose significant challenges in achieving successful outcomes. The efficacy of existing pharmacological studies, such as α-adrenergic blocking agents, antidepressants, and atypical antipsychotics, has been undermined by methodological limitations and absence of large randomized controlled trials. This review is aimed at reviewing the available treatment strategies for alleviating nightmares in subjects with PTSD. Given the intricate relationship between PTSD and nightmares, future clinical trials have to adopt a more pragmatic approach focused not only on efficacy of novel interventions but also on adjunctive iteration of existing therapies tailored to individual socio-cultural background.

Treatment of Post-Traumatic Stress Disorder Nightmares at a Veterans Affairs Medical Center

The effectiveness of medications for PTSD in general has been well studied, but the effectiveness of medicatio.ns prescribed specifically for post-traumatic stress disorder (PTSD) nightmares is less well known. This retrospective chart review examined the efficacy of various medications used in actual treatment of PTSD nightmares at one Veteran Affairs Hospital. Records at the Salem, VA Veterans Affairs Medical Center (VAMC) were examined from 2009 to 2013 to check for the efficacy of actual treatments used in comparis.on with treatments suggested in three main review articles. The final sample consisted of 327 patients and 478 separate medication trials involving 21 individual medications plus 13 different medication combinations. The three most frequently utilized medications were prazosin (107 trials), risperidone (81 trials), and quetiapine (72 trials). Five medications had 20 or more trials with successful results (partial to full nightmare cessation) in >50% of trials: risperidone (77%, 1.0–6.0 mg), clonidine (63%, 0.1–2.0 mg), quetiapine (50%, 12.5–800.0 mg), mirtazapine (50%; 7.5–30.0 mg), and terazosin (64%, 50.0–300.0 mg). Notably, olanzapine (2.5–10.0) was successful (full remission) in all five prescription trials in five separate patients. Based on the clinical results, the use of risperidone, clonidine, terazosin, and olanzapine warrants additional investigation in clinically controlled trials as medications prescribed specifically for PTSD nightmares.

Adverse Effects of Psychotropic Medications on Sleep

Psychotropic medications such as antidepressants, antipsychotics, stimulants, and benzodiazepines are widely prescribed. Most of these medications are thought to exert their effects through modulation of various monoamines as well as interactions with receptors such as histamine and muscarinic cholinergic receptors. Through these interactions, psychotropics can also have a significant impact on sleep physiology, resulting in both beneficial and adverse effects on sleep.

Pharmacology for sleep disturbance in PTSD

Symptoms of sleep disturbance, particularly nightmares and insomnia, are a central feature of post-traumatic stress disorder (PTSD). Emerging evidence suggests that specific treatment of PTSD-related sleep disturbance improves other symptoms of the disorder, which in turn suggests that such disturbance may be fundamental to development and maintenance of the disorder. This mini-review focuses on pharmacological treatment of sleep disturbance in adult PTSD (specifically, studies testing the efficacy of antidepressants, adrenergic inhibiting agents, antipsychotics and benzodiazepine and non-benzodiazepine hypnotics). We conclude that only prazosin, an adrenergic inhibiting agent, has had its efficacy established by multiple randomised controlled trials. There is also high-level evidence supporting use of eszopiclone, as well as risperidone and olanzapine as adjunct therapy. Antidepressants such as sertraline, venlafaxine and mirtazapine, benzodiazepines such as alprazolam and clonazepam and non-benzodiazepine hypnotics such as zolpidem appear ineffective in treating PTSD-related sleep disturbance. Most studies that report reduced frequency of nightmares and insomnia also report decreases in overall symptom severity. Such findings suggest that (i) sleep disruption is central to PTSD; (ii) treating sleep disruption may be an effective way to address other symptoms of the disorder and (iii) PTSD symptoms tend to cluster together in predictable ways.

Effects of quetiapine treatment on cocaine self-administration and behavioral indices of sleep in adult rhesus monkeys

RATIONALE

Clinical literature suggests a link between substance abuse and sleep disturbances. Quetiapine, an atypical antipsychotic, has shown efficacy in treating sleep disturbances, with clinical studies showing promise for quetiapine as a treatment for cocaine abuse.

OBJECTIVE

The goal of this study was to examine the effects of quetiapine on cocaine self-administration and behavioral indices of sleep in monkeys.

METHODS

Seven adult male rhesus monkeys, fitted with Actical® activity monitors, were trained to respond under a choice paradigm of food (1.0-g pellets) and cocaine (0.003-0.3 mg/kg per injection) presentation. First, monkeys received acute pretreatment (45 min) with quetiapine (25-75 mg, p.o.) prior to choice sessions; three cocaine doses were studied in combination with quetiapine. Next, the effect of chronic (14-16 days) quetiapine treatment (25-250 mg, p.o., BID) was examined in combination with the lowest preferred cocaine dose (≥80 % cocaine choice). Behavioral indices of sleep, based on activity measures obtained during lights-out, were recorded throughout the study.

RESULTS

Acute quetiapine decreased cocaine choice in four of the seven monkeys. Chronic quetiapine treatment resulted in initial decreases in cocaine choice, but tolerance developed to these effects. Acute doses of quetiapine did not improve sleep efficiency the following night nor did chronic quetiapine. The first night after discontinuing quetiapine treatment resulted in significant decreases in sleep efficiency and increases in nighttime activity.

CONCLUSIONS

These findings do not offer support for the use of quetiapine as a monotherapy for treatment of cocaine abuse nor as an adjunct therapy to treat sleep disturbances associated with stimulant abuse.

The use of second generation antipsychotics for post-traumatic stress disorder in a US Veterans Health Administration Medical Center

Background. Prior studies of antipsychotic use in individuals with post-traumatic stress disorder (PTSD) are limited because administrative data lacks information on why providers choose particular medications. Methods. This study examined 2613 provider surveys completed at the time any second generation antipsychotic (SGA) was prescribed over a 20-month period at a single Veterans Affairs medical center. Clinical correlates and reasons for SGA selection among individuals with PTSD compared to those with other psychiatric disorders were identified using chi-square. Results. PTSD was the sole diagnosis in n = 339 (13%) and one of several psychiatric diagnoses in n = 236 (9%) surveys. 'Efficacy' was the most common reason given for the prescriptions of SGAs in all surveys (51%) and among individuals with PTSD (46%). 'Sleep/sedation' was the only reason cited, significantly more frequently among those with PTSD (39% with PTSD only, 35% with PTSD plus another diagnosis, and 31% without PTSD [χ 2 = 12.86, p < 0.0016)]. The proportion identifying 'efficacy' as a reason for SGA use was smaller in patients with PTSD (44% with PTSD only, 49% with PTSD and another diagnosis, and 53% without PTSD [χ 2 = 8.78, p < 0.0125)]. Quetiapine was the most frequently prescribed SGA in the entire sample and among veterans with PTSD (47%). Conclusions. Clinician use of SGAs is often driven by efficacy, for which there is limited evidence, and distinctly driven by the goal of sedation among patients with PTSD.

Off-label use of atypical antipsychotic agents for treatment of insomnia

Despite limited supporting evidence, off-label uses of atypical or second generation antipsychotics (particularly olanzapine, quetiapine, and risperidone) are not uncommon. The off-label use of these agents for the treatment of insomnia is the focus of this review. While atypical antipsychotics are associated with a lower risk of tardive dyskinesia, extrapyramidal side effects, and more favorable effects on cognitive deficits and negative symptomatology in schizophrenic patients compared to typical or first generation antipsychotic agents, they are not without risks. Metabolic adverse effects are particularly problematic with atypical antipsychotics, even at doses lower than those used to treat FDA-approved indications. The receptor affinity profiles of most atypical antipsychotic agents promote sedation. The level of H1-histamine receptor blockade is believed to be most associated with somnolence and sedation. Several studies evaluating the safety and efficacy of the atypical antipsychotics quetiapine, olanzapine, and risperidone for the treatment of insomnia were identified and are summarized in this article.

A review of atypical antipsychotics and their utility in post-traumatic stress disorder

Post traumatic stress disorder (PTSD) is a chronic and debilitating mental illness. Atypical antipsychotics are often utilized for treatment of PTSD despite the limited data. The purpose of this article is to review published clinical trials of atypical antipsychotics used in the treatment of PTSD. Certain patients may benefit from therapy with an atypical antipsychotic, particularly for those with hyper-arousal or re-experiencing symptom clusters. At this time, guidelines suggest against the use of risperidone as augmentation therapy in patients with PTSD. Data are only available for olanzapine, quetiapine, and aripiprazole; however, data were conflicting, not very robust, and studies had limited sample sizes and narrow demographics. It is important to provide proper patient education and weigh the risks versus benefits of therapy with an atypical antipsychotic as metabolic side effects are well documented.

Low-dose quetiapine for adolescents with autistic spectrum disorder and aggressive behavior: open-label trial

BACKGROUND

Atypical antipsychotics may be useful in treating aggression associated with autistic spectrum disorder (ASD). We evaluated the effectiveness of low-dose quetiapine treatment in ASD adolescent patients with aggressive behavior.

METHOD

Eleven adolescent patients (8 boys and 3 girls) diagnosed with ASD, aged 13 to 17 years, were treated with quetiapine in an open-label study over an 8-week period. The severity of ASD, aggressive behavior, and sleep disturbances were assessed using the Clinical Global Impression-Severity (CGI-S), Overt Aggression Scale, and Child Sleep Habits Questionnaire, respectively.

RESULTS

Nonsignificant changes were obtained in autistic behavior after quetiapine treatment (CGI-S: 4.0 ± 0.6 vs CGI-S after: 3.1 ± 1.1; 2-tailed paired t = 1.93; df = 10; P = 0.08). Severity of aggressive behavior decreased significantly after quetiapine treatment (Overt Aggression Scale: 2.1 ± 0.94 vs 1.3 ± 0.64, respectively; 2-tailed paired t = 2.37; df =10; P = 0.028). Sleep disturbances improved significantly (Child Sleep Habits Questionnaire: 49.0 ± 12 vs 44.1 ± 9.6; 2-tailed paired t = 2.98; df =10; P = 0.014) and a positive correlation was found between the improvements in aggression and sleep (Spearman correlation: r = 0.43; N = 11; P = 0.013). Quetiapine was well tolerated.

CONCLUSION

Short-term low-dose quetiapine treatment may reduce aggression levels and improve sleep quality in adolescents with ASD.

Targeting memory processes with drugs to prevent or cure PTSD

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a chronic debilitating psychiatric disorder resulting from exposure to a severe traumatic stressor and an area of great unmet medical need. Advances in pharmacological treatments beyond the currently approved SSRIs are needed.

AREAS COVERED

Background on PTSD, as well as the neurobiology of stress responding and fear conditioning, is provided. Clinical and preclinical data for investigational agents with diverse pharmacological mechanisms are summarized.

EXPERT OPINION

Advances in the understanding of stress biology and mechanisms of fear conditioning plasticity provide a rationale for treatment approaches that may reduce hyperarousal and dysfunctional aversive memories in PTSD. One challenge is to determine if these components are independent or reflect a common underlying neurobiological alteration. Numerous agents reviewed have potential for reducing PTSD core symptoms or targeted symptoms in chronic PTSD. Promising early data support drug approaches that seek to disrupt dysfunctional aversive memories by interfering with consolidation soon after trauma exposure, or in chronic PTSD, by blocking reconsolidation and/or enhancing extinction. Challenges remain for achieving selectivity when attempting to alter aversive memories. Targeting the underlying traumatic memory with a combination of pharmacological therapies applied with appropriate chronicity, and in combination with psychotherapy, is expected to substantially improve PTSD treatment.

A double-blind, placebo-controlled trial to assess the efficacy of quetiapine fumarate XR in very heavy-drinking alcohol-dependent patients

BACKGROUND

Despite advances in developing medications to treat alcohol dependence, few such medications have been approved by the Food and Drug Administration. Identified molecular targets are encouraging and can lead to the development and testing of new compounds. Atypical antipsychotic medications have been explored with varying results. Prior research suggests that the antipsychotic quetiapine may be beneficial in an alcohol-dependent population of very heavy drinkers.

METHODS

In this double-blind, placebo-controlled trial, 224 alcohol-dependent patients who reported very heavy drinking were recruited across 5 clinical sites. Patients received either quetiapine or placebo and Medical Management behavioral intervention. Patients were stratified on gender, clinical site, and reduction in drinking prior to randomization.

RESULTS

No differences between the quetiapine and placebo groups were detected in the primary outcome, percentage heavy-drinking days, or other drinking outcomes. Quetiapine significantly reduced depressive symptoms and improved sleep but had no effect on other nondrinking outcomes. Results from a subgroup analysis suggest that patients who reduced their drinking prior to randomization had significantly better drinking outcomes during the maintenance phase (p < 0.0001). No significant interactions, however, were observed between reducer status and treatment group. Finally, quetiapine was generally well tolerated. Statistically significant adverse events that were more common with quetiapine versus placebo include dizziness (14 vs. 4%), dry mouth (32 vs. 9%), dyspepsia (13 vs. 2%), increased appetite (11 vs. 1%), sedation (15 vs. 3%), and somnolence (34 vs. 9%).

CONCLUSIONS

This multisite clinical trial showed no efficacy for quetiapine compared with placebo at reducing alcohol consumption in heavy-drinking alcohol-dependent patients.

Review of atypical antipsychotics in anxiety

Atypical antipsychotics are increasingly used for treatment of anxiety disorders, either in mono- or combination therapy. This is the first review reporting on the use of atypical antipsychotics in monotherapy or augmentation in patients with primary anxiety disorders or anxiety (disorders) comorbid to schizophrenia, bipolar disorder (BPD) and major depressive disorder (MDD). We included 49 open-label trials, 32 randomized, placebo-controlled trials (RCTpls) and five randomized controlled trials without placebo arm with almost 6000 patients (open-label: 1710, randomized: 4145). An increasing number of RCTpls show promising results in 27-71% of patients with primary or comorbid anxiety disorders who were treated with monotherapy atypical antipsychotics or augmentation therapy. However, methodological flaws of included studies may limit conclusions of this review and larger placebo-controlled trials are warranted comparing standard treatment with monotherapy and augmentation therapy of atypical antipsychotics and placebo. In addition, higher dropout rates and side effects from treatment with atypical antipsychotics may limit the use of atypical antipsychotics in patients with anxiety disorders.

Post-traumatic stress disorder: present and future

Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) differ from almost every other psychiatric diagnosis in that they may only be diagnosed with reference to an aetiological event - an external traumatic stressor. ASD occurs immediately after the stressor and is comparatively short-lived, while PTSD is a prolonged abnormal response that may take months to develop. The types of stressor leading to ASD and PTSD are identical and were intended to be tightly defined, involving a perceived threat of death, serious injury or loss of physical integrity. It is useful initially to distinguish ASD and PTSD from adjustment disorders, which are also diagnosed only after an observable life event. An adjustment disorder may be thought of as a gradual and prolonged response to stressful changes in a person's life. The range of stressors precipitating an adjustment disorder is potentially much broader than that precipitating ASD or PTSD, as a threat of death or injury is not needed. Indeed, a 'threat' as such is not needed, as the event may be a loss. Events such as job loss or the breakup of a relationship may lead to an adjustment disorder, as well as threats such as accidents or assaults. The diagnostic criteria for adjustment disorder do not specify what the immediate response, if any, to the precipitating stressor must be.

Sleep in psychiatric disorders: where are we now?

Although the precise function of sleep is unknown, decades of research strongly implicate that sleep has a vital role in central nervous system (CNS) restoration, memory consolidation, and affect regulation. Slow-wave sleep (SWS) and rapid eye movement (REM) sleep have been of significant interest to psychiatrists; SWS because of its putative role in CNS energy recuperation and cognitive function, and REM sleep because of its suggested involvement in memory, mood regulation, and possible emotional adaptation. With the advent of the polysomnogram, researchers are now beginning to understand some of the consequences of disrupted sleep and sleep deprivation in psychiatric disorders. The same neurochemistry that controls the sleep-wake cycle has also been implicated in the pathophysiology of numerous psychiatric disorders. Thus it is no surprise that several psychiatric disorders have prominent sleep symptoms. This review will summarize normal sleep architecture, and then examine sleep abnormalities and comorbid sleep disorders seen in schizophrenia, as well as anxiety, cognitive, and substance abuse disorders.

Poor reported sleep quality predicts low positive affect in daily life among healthy and mood-disordered persons

Sleep disturbance is a core symptom of mood disorders. However, surprisingly little is known about the relationship between sleep quality and ambulatory daily mood, especially in mood-disordered populations. We assessed ambulatory positive affect (PA) and negative affect (NA) 10 times daily for three consecutive days with the computerized experience sampling method among persons with major depression (n = 35), minor depression (n = 25) and healthy controls (n = 36). Sleep quality was assessed with the Pittsburgh Sleep Quality Index (PSQI). Poorer sleep quality predicted lower ambulatory PA, even after accounting for the effects of diagnostic group and self-reported anxiety. Conversely, sleep quality did not predict ambulatory NA once diagnostic group was accounted for. Analyzes of specific PSQI component scores indicated that poor subjective sleep quality and self-reported daytime dysfunction were the sleep components most strongly tied to reports of low ambulatory PA. Impaired sleep quality may be responsible for reduced pleasurable experience in everyday life.

Update on sleep and psychiatric disorders

Current data demonstrate a high rate of comorbidity between sleep disorders and various psychiatric illnesses, especially mood and anxiety disorders. The disturbance of sleep quality and continuity that is associated with many sleep disorders predisposes to the development or exacerbation of psychological distress and mental illness. Likewise, the presence of psychiatric illness may complicate the diagnosis and treatment of sleep disorders. This focused review examines the literature concerning the interaction between major International Classification of Sleep Disorders, 2nd edition, diagnoses and psychiatric conditions with respect to sleep findings in various psychiatric conditions, psychiatric comorbidity in sleep disorders, and reciprocal interactions, including treatment effects. The data not only underscore the high frequency of psychopathology and psychological distress in sleep disorders, and vice versa, but also suggest that combined treatment of both the mental disorder and the sleep disorder should become the standard for effective therapy for all patients.

Effects of Quetiapine on Sleep in Nonpsychiatric and Psychiatric Conditions

Objective:

To evaluate the use of immediate-release quetiapine for the treatment of insomnia.

Data Sources:

Pre-MEDLINE and MEDLINE were searched (1966 to October 2008) using the terms quetiapine, sleep, insomnia, and antipsychotics.

Study Selection and Data Extraction:

All studies and case reports evaluating insomnia as a primary endpoint were reviewed.

Data Synthesis:

The role of quetiapine for improving sleep in various patient populations is uncertain. Quetiapine has moderately sedative properties, and closes used in treatment of insomnia have ranged from 12.5 to 800 mg. Results of clinical trials and observations in case studies have revealed possible beneficial effects of quetiapine on several subjective and objective sleep parameters. In most studies, significant improvements in sleep were found in areas of total sleep time, sleep efficiency, and subjective sleep scores. However, some of these results may not be clinically significant. Also, quetiapine has been found to have adverse effects such as periodic leg movements, akathisia, and metabolic complications. Additionally, changes in rapid eye movement (REM) and percentage of REM sleep have been noted in different populations and need further study. Despite quetiapine's sedative properties, current data do not appear to support its use as first-line treatment for sleep complications. However, it may be useful for treatment of insomnia in patients with psychiatric disorders (eg, bipolar, schizophrenia) who do not respond to primary or secondary treatments.

Conclusions:

Further studies are needed to define the placement, dose, and adverse effects of quetiapine for the treatment of sleep problems.

Pharmacologic alternatives to antidepressants in posttraumatic stress disorder: a systematic review

The selective serotonin reuptake inhibitors (SSRIs) are considered the first-line pharmacological treatment for PTSD. However, even when treated with this class of drugs, response rates rarely exceed 60% and less than 20-30% of the patients achieve full remission. The aim of this study was to address this limitation by systematically reviewing the options left for the treatment of PTSD when patients do not respond satisfactorily to or tolerate SSRIs. A systematic review covering all original articles, letters and brief reports published in any language until October 2008 was conducted through searches in the ISI/Web of Science, PubMed and PILOTS databases. The search terms included the pharmacological class of each agent or its generic name plus "PTSD" or "stress disorder" in the title, in the abstract or as a keyword. Sixty-three articles were selected, covering the following categories: antipsychotics, anticonvulsants, adrenergic-inhibiting agents, opioid antagonists, benzodiazepines and other agents. None of the identified agents reached the level A of scientific evidence, 5 reached level B, 7 level C and 13 level D. The non-antidepressant agent with the strongest scientific evidence supporting its use in PTSD is risperidone, which can be envisaged as an effective add-on therapy when patients did not fully benefit from previous treatment with SSRIs. Prazosin, an adrenergic-inhibiting agent, is a promising alternative for cases of PTSD where nightmares and insomnia are prominent symptoms. So far, there is no consistent empirical support for using benzodiazepines in the prevention or in the treatment of PTSD, although these drugs could alleviate some associated non-specific symptoms, such as insomnia or anxiety. Further controlled clinical trials and meta-analysis are needed to guide clinicians in their search of effective pharmacological alternatives to antidepressants in PTSD.

Reduced GABAA benzodiazepine receptor binding in veterans with post-traumatic stress disorder

Gamma-aminobutyric acid (GABA(A)) receptors are thought to play an important role in modulating the central nervous system in response to stress. Animal data have shown alterations in the GABA(A) receptor complex by uncontrollable stressors. SPECT imaging with benzodiazepine ligands showed lower distribution volumes of the benzodiazepine-GABA(A) receptor in the prefrontal cortex of patients with post-traumatic stress disorder (PTSD) in one, but not in another study. The objective of the present study was to assess differences in the benzodiazepine-GABA(A) receptor complex in veterans with and without PTSD using [(11)C]flumazenil and positron emission tomography (PET). Nine drug naive male Dutch veterans with deployment related PTSD and seven male Dutch veterans without PTSD were recruited, and matched for age, region and year of deployment. Each subject received a [(11)C]flumazenil PET scan and a structural magnetic resonance imaging scan. Dynamic 3D PET scans with a total duration of 60 min were acquired, and binding in template based and manually defined regions of interest (ROI) was quantified using validated plasma input and reference tissue models. In addition, parametric binding potential images were compared on a voxel-by-voxel basis using statistical parametric mapping (SPM2). ROI analyses using both template based and manual ROIs showed significantly reduced [(11)C]flumazenil binding in PTSD subjects throughout the cortex, hippocampus and thalamus. SPM analysis confirmed these results. The observed global reduction of [(11)C]flumazenil binding in patients with PTSD provides circumstantial evidence for the role of the benzodiazepine-GABA(A) receptor in the pathophysiology of PTSD and is consistent with previous animal research and clinical psychopharmacological studies.

Pharmacotherapeutic treatment of nightmares and insomnia in posttraumatic stress disorder: an overview of the literature

Sleep disturbances are hallmark symptoms of posttraumatic stress disorder (PTSD). Where the subjective experience of nightmares and insomnia in PTSD patients is very real indeed and demands treatment, objective research findings on disordered sleep architecture in PTSD are inconclusive and inconsistent. After reviewing the literature an insufficient number of controlled studies are published to formulate evidence-based guidelines. Several studies have methodological limitations, such as small group sizes and heterogenic samples. Large randomized controlled trials (RCTs) need to be conducted in order to further develop adequate therapeutic interventions. Objective parameters for insomnia and nightmares need to be identified for understanding underlying mechanisms of disturbed sleep in PTSD, and for evaluating therapy.

Sleep disturbances in patients with post-traumatic stress disorder: epidemiology, impact and approaches to management

Subjective reports of sleep disturbance indicate that 70-91% of patients with post-traumatic stress disorder (PTSD) have difficulty falling or staying asleep. Nightmares are reported by 19-71% of patients, depending on the severity of their PTSD and their exposure to physical aggression. Objective measures of sleep disturbance are inconsistent, with some studies that used these measures indicating poor sleep and others finding no differences compared with non-PTSD controls. Future research in this area may benefit from examining measures of instability in the microstructure of sleep. Additionally, recent findings suggest that sleep disordered breathing (SDB) and sleep movement disorders are more common in patients with PTSD than in the general population and that these disorders may contribute to the brief awakenings, insomnia and daytime fatigue in patients with PTSD. Overall, sleep problems have an impact on the development and symptom severity of PTSD and on the quality of life and functioning of patients. In terms of treatments, SSRIs are commonly used to treat PTSD, and evidence suggests that they have a small but significant positive effect on sleep disruption. Studies of serotonin-potentiating non-SSRIs suggest that nefazodone and trazodone lead to significant reductions in insomnia and nightmares, whereas cyproheptadine may exacerbate sleep problems in patients with PTSD. Prazosin, a centrally acting alpha1-adrenoceptor antagonist, has led to large reductions in nightmares and insomnia in small studies of patients with PTSD. Augmentation of SSRIs with olanzapine, an atypical antipsychotic, may be effective for treatment-resistant nightmares and insomnia, although adverse effects can be significant. Additional medications, including zolpidem, buspirone, gabapentin and mirtazapine, have been found to improve sleep in patients with PTSD. Large randomised, placebo-controlled trials are needed to confirm the above findings. In contrast, evidence suggests that benzodiazepines, TCAs and MAOIs are not useful for the treatment of PTSD-related sleep disorders, and their adverse effect profiles make further studies unlikely. Cognitive behavioural interventions for sleep disruption in patients with PTSD include strategies targeting insomnia and imagery rehearsal therapy (IRT) for nightmares. One large randomised controlled trial of group IRT demonstrated significant reductions in nightmares and insomnia. Similarly, uncontrolled studies combining IRT and insomnia strategies have demonstrated good outcomes. Uncontrolled studies of continuous positive airway pressure for SDB in patients with PTSD show that this treatment led to significant decreases in nightmares, insomnia and PTSD symptoms. Controlled studies are needed to confirm these promising findings.

Quetiapine augmentation in treatment-resistant depression: a naturalistic study

RATIONALE

Treatment-resistant depression (TRD) is a common clinical problem, often complicated with suicidal ideations and greater lifetime functional impairment, and represents a considerable challenge to management and treatment.

OBJECTIVE

The aim of a prospective, open-label, noncomparative, flexible-dosed 20-week study was to evaluate the effects of quetiapine, as an add-on therapy, in patients with TRD who were refractory to previous treatments.

METHOD

Eighteen patients with major depressive disorder (DSM-IV criteria) were treated for 20 weeks with quetiapine (mean dose 315+/-109 mg/day). Patients were evaluated at baseline, weekly from 1 to 9 weeks, and then after 12, 16, and 20 weeks of treatment, using Hamilton rating scale for depression-17 items (HAMD) scale.

RESULTS

Fourteen patients with TRD completed the 20-week open trial with quetiapine. The augmentation with quetiapine significantly reduced total scores and scores listed in the anxiety subscale on the HAMD, and these effects were observed after the fourth week of treatment, while the depressed mood scores were significantly reduced after the fifth week of treatment. Quetiapine add-on treatment significantly decreased the scores listed in the insomnia subscale on the HAMD subscale after the second week of treatment.

CONCLUSION

Our preliminary data indicate that quetiapine add-on therapy appears to have beneficial effects in the treatment of patients with TRD.

Pharmacotherapy for disordered sleep in post-traumatic stress disorder: a systematic review

Sleep disorders, such as insomnia and nightmares, are common problems in post-traumatic stress disorder (PTSD), exert a strong negative influence on the quality of life and are a great challenge for clinical psychiatry. Several studies have reported on the efficacy of drugs for the treatment of PTSD-related sleep disorders. These studies have not been systematically reviewed. This is the first review on the effectiveness of sleep medication in PTSD. We performed a Medline, EMBASE and Cochrane Library Indexed search, using the keywords: PTSD, pharmacotherapy, therapy, sleep, nightmares, insomnia and review. From this database, English-language, human subject, data driven papers published after 1980 were selected. Forty eight articles are discussed. Open-label and case studies suggest efficacy for some antidepressants, anticonvulsants and atypical antipsychotics. Only a few placebo-controlled studies have been published. They show promising results for the atypical antipsychotic olanzapine, and the alpha1-adrenoceptor antagonist prazosin. In comparison to the incidence and impact of sleep complaints in PTSD, the pharmacotherapeutic armamentarium for PTSD-related sleep complaints remains poorly investigated. Some recent studies show promising results, especially for alpha1-adrenoceptor and 5-HT2 receptor antagonists. However, randomized controlled trials with larger populations need to be conducted.